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The gastrointestinal tract. The "undrained abscess" of multiple organ failure
J C Marshall1, N V Christou, J L Meakins
1Department of Surgery, University of Toronto, Ontario, Canada.
Objective:
This study determined the association between proximal gastrointestinal (GI) colonization and the development of intensive care unit (ICU)-acquired infection and multiple organ failure (MOF) in a population of critically ill surgical patients.
Summary Background Data:
ICU-acquired infection in association with progressive organ system dysfunction is an important cause of morbidity and mortality in critical surgical illness. Oropharyngeal and gastric colonization with the characteristic infecting species is common, but its association with ICU morbidity is poorly defined.
Methods:
A prospective cohort study of 41 surgical ICU patients was undertaken. Specimens of gastric and upper small bowel fluid were obtained for quantitative culture; the severity of organ dysfunction was quantitated by a numeric score.
Results:
One or more episodes of ICU-acquired infection developed in 33 patients and involved at least one organism concomitantly cultured from the upper GI tract in all but 3. The most common organisms causing ICU-acquired infection--Candida, Streptococcus faecalis, Pseudomonas, and coagulase-negative Staphylococci--were also the most common species colonizing the proximal GI tract. Gut colonization correlated with the development of invasive infection within 1 week of culture for Pseudomonas (90% vs. 13% in noncolonized patients, p < 0.0001) or Staphylococcus epidermidis (80% vs. 6%, p < 0.0001); a weaker association was seen for colonization with Candida. Infections associated with GI colonization included pneumonia (16 patients), wound infection (12 patients), urinary tract infection (11 patients), recurrent (tertiary) peritonitis (11 patients), and bacteremia (10 patients). ICU mortality was greater for patients colonized with Pseudomonas (70% vs. 26%, p = 0.03); organ dysfunction was most marked in patients colonized with one or more of the following: Candida, Pseudomonas, or S. epidermidis.
Conclusions:
The upper GI tract is an important reservoir of the organisms causing ICU-acquired infection. Pathologic GI colonization is associated with the development of MOF in the critically ill surgical patient.
Insights
Proximal gastrointestinal (GI) colonization is a significant reservoir for intensive care unit (ICU)-acquired infections in critically ill surgical patients. This gut colonization is strongly linked to the development of multiple organ failure (MOF).
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Surgical Outcomes
Background:
- Intensive care unit (ICU)-acquired infections and progressive organ system dysfunction contribute significantly to morbidity and mortality in critically ill surgical patients.
- While oropharyngeal and gastric colonization are common, their direct association with ICU morbidity remains poorly defined.
Purpose of the Study:
- To determine the association between proximal gastrointestinal (GI) colonization and the development of ICU-acquired infections.
- To investigate the link between proximal GI colonization and multiple organ failure (MOF) in critically ill surgical patients.
Main Methods:
- A prospective cohort study involving 41 surgical ICU patients.
- Quantitative cultures of gastric and upper small bowel fluid specimens were performed.
- Severity of organ dysfunction was assessed using a standardized numeric score.
Main Results:
- ICU-acquired infections developed in 33 patients, with causative organisms often cultured from the proximal GI tract.
- Common ICU pathogens like Candida, Pseudomonas, and Staphylococcus epidermidis were frequently found colonizing the GI tract.
- GI colonization correlated significantly with invasive infections (e.g., Pseudomonas, S. epidermidis) and increased ICU mortality, particularly with Pseudomonas colonization.
Conclusions:
- The upper GI tract serves as a critical reservoir for pathogens causing ICU-acquired infections.
- Pathological GI colonization is a significant risk factor associated with the development of multiple organ failure (MOF) in critically ill surgical patients.